GW1-2022-09454_Well Construction - GW1_20221017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
GARRETT CLYDE BANKS F4.WATERZONES
FROM 'r0 DESCRIPTION
Well Connector Name
ft. ft. i
4519-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedwells)OR LINER(i pGcable)
FRODI TO I DIAMETER! THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 93 ft. 6 1/8 ' 1n #21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2022-00129 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State.Variance,hjection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Initiation 0 fr. 20 ft- Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑ FROM Salinity Barrier ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRiLL1NG LOG(attach addition alsheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 fc• 93 ft OVER BURDEN
9-15-2022 93 ft- 405 ft- GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location:
McMaster Real Estate Group
ft. rt.Facility/Owner Name Facility lD#(ifapplicable) ft. ft. 2
16 MTN Road Arden, NC 28704 ft. ft. tf,:,.,,c- 'rC - Unl
> ,:. j
Physical Address,City,and Zip 2L REMARKS "'`7:z;(..a`-'
Buncombe 96543927550000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(if well field,one eat/long is sufficient)
N 9-16-2022
Signature of Cerh Well Contractor Dale
6.Is(are)the well(s): OPermanent or ❑Temporary Br signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
ll'thi.v is a repair,fJill out known well construction in/orntation and explain the natw•e ofthe
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one/onn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2G100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
#hater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
2 RIG 24c.For Water Supply&Injection,Wells:
,.
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed.
t
Foram GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013